# Successful double valve replacement with extensive annular enlargement using the Commando procedure in a patient with small aortic and mitral annuli after previous double valve surgery

## TL;DR

A 70-year-old woman successfully underwent a complex heart valve surgery to replace both her aortic and mitral valves after previous surgery, avoiding complications from mismatched valve sizes.

## Contribution

The study demonstrates the successful use of the Commando procedure for extensive annular enlargement in redo double valve surgery.

## Key findings

- The Commando procedure allowed safe and simultaneous enlargement of both aortic and mitral annuli.
- Postoperative echocardiography showed excellent hemodynamics with no major complications.
- The patient remains asymptomatic, preserving future valve-in-valve therapy options.

## Abstract

We report a 70-year-old woman (body surface area 1.42 m2) undergoing redo double valve replacement with extensive annular enlargement using the Commando procedure. Thirteen years earlier, she received aortic valve replacement (St. Jude Medical 19 mm), mitral repair (Physio Ring 24 mm), and tricuspid annuloplasty. She presented with progressive heart failure; echocardiography showed severe mitral stenosis (mitral valve area 0.96 cm2) and moderate aortic stenosis with moderate paravalvular leak. To avert patient–prosthesis mismatch (PPM), both annuli were enlarged with bovine pericardium, permitting implantation of an Epic 27 mm mitral and an Inspiris 23 mm aortic bioprosthesis. Postoperative echocardiography demonstrated excellent hemodynamics (aortic effective orifice area 1.76 cm2, mean gradient 6 mmHg; mitral mean gradient 3 mmHg). Recovery was uneventful, and she remains asymptomatic. Commando surgery enabled safe, simultaneous enlargement of both annuli, minimizing PPM, and preserving options for future valve-in-valve therapy.